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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009498
Report Date: 11/01/2023
Date Signed: 11/01/2023 02:01:11 PM

Document Has Been Signed on 11/01/2023 02:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BAUSLEY, JACKIELYN FCCHFACILITY NUMBER:
493009498
ADMINISTRATOR:BAUSLEY, JACKIELYNFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 888-5130
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 14TOTAL ENROLLED CHILDREN: 13CENSUS: 11DATE:
11/01/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Jackielyn BausleyTIME COMPLETED:
02:15 PM
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An annual required inspection was made to the facility by Licensing Program Analyst (LPA), Amy Strother. LPA met with Licensee, Jackielyn Bausley (L1). L1 was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

During the inspection the home was toured inside and outside. During today’s visit, two assistants (S1 and S2) and L1 were supervising children, 2 infants, 7 preschool age children and 2 school age children for a total of 11 children, and operating within the licensed capacity and ratio requirements. L1 provided a current roster of children in care as required. LPA verified that the children present were listed on the roster. The facility’s operating hours are Monday – Sunday 6:00AM -11:00PM. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are the entire upstairs level of the home, the garage, and the kitchen. Upstairs and the kitchen are made inaccessible by child safety gates. During today's visit the garage door was unlocked and the child safety gate at the living room was open, making it accessible to children in care. LPA observed the following hazards to include, but not limited to cleaning products, lighters and smoking cigars in the garage. Licensee locked the garage door when requested by LPA. The home appears to be clean and orderly and was at a comfortable indoor temperature. There were safe toys and equipment available for children. There is a working telephone in the home. Items which could pose a danger to children (such as detergents, cleaning compounds, medications, etc.) were observed to be accessible in the bathroom used by the children. LPA observed the following cleaning products in the bathroom cupboard under the bathroom sink: Comet, Lysol spray and carpet cleaner. Licensee removed the cleaning products when requested by LPA, storing them out of reach of children. LPA suggested adding child safety locks to bathroom cupboard storage, if she desires to keep cleaning products in the bathroom.

Continued on LIC 809-C

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BAUSLEY, JACKIELYN FCCH
FACILITY NUMBER: 493009498
VISIT DATE: 11/01/2023
NARRATIVE
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Licensee stated that there are no poisons stored in the home, and none were observed during today's visit. The fireplace is barricaded and has been made inaccessible. LPA observed a working smoke detector, carbon monoxide detector and a fire extinguisher, rated at least 2A10BC that appeared to be fully charged, in the home. The licensee stated that she has conducted an emergency drill within the past six months, on 05/10/23, but did not have documentation available for review. At 10:35am Licensee stated that she was unable to find her drill log and does not have the date of the drill documented anywhere else. The licensee stated there are no firearms and/or other dangerous weapons in the home and none were observed during today's inspection. Five children's records were reviewed and contained required records. Facility and personnel files were reviewed and contained required records.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the Licensee, confirmed that there are no Registered Sex Offenders living in the facility and LPAs completed the RSO profile in FAS.

Continue on LIC809-C

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BAUSLEY, JACKIELYN FCCH
FACILITY NUMBER: 493009498
VISIT DATE: 11/01/2023
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To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided.

A notice of site visit was given to licensee and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

Exit interview conducted and report was reviewed with the licensee Jackielyn Bausley.

LPA Strother informed licensee Jackielyn Bausley that this report dated 11/01/23 documents one Type A citation. Type A citations shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Strother informed the licensee to provide a copy of this licensing report dated 11/01/23 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023
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Document Has Been Signed on 11/01/2023 02:01 PM - It Cannot Be Edited


Created By: Amy Strother On 11/01/2023 at 01:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BAUSLEY, JACKIELYN FCCH
FACILITY NUMBER: 493009498

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 areas of the home. LPA observed the cabinets under the sink in the bathroom used by children were not locked and contained cleaning compounds. LPA observed Comet, Lysol spray and carpet cleaner under the sink. Additionally the "off-limits" garage door was unlocked and accessible to children in care. Although there is a child safety gate prior to the garage door, the gate was open and LPA observed child (C9) walk through the gate, past the garage door and into the family room. LPA observed cleaning products, lighters, cigars and an ashtray in the accessible garage, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/02/2023
Plan of Correction
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Licensee removed hazards during visit by removing cleaners from under accessible bathroom cupboard and locking the garage door with a key lock. Licensee stated that she will be adding child safety locks to the bathroom cupboards and all adults in the home will sign a statement agreeing to keep the garage door locked at all times during child care hours. Licensee provided signed statement to LPA during today's visit. Licensee will submit photo of child safety locks to LPA Strother by 11/08/23 submitting to amy.strother@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Alexis Hollon
LICENSING EVALUATOR NAME:Amy Strother
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2023


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 11/01/2023 02:01 PM - It Cannot Be Edited


Created By: Amy Strother On 11/01/2023 at 01:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BAUSLEY, JACKIELYN FCCH
FACILITY NUMBER: 493009498

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in that although the licensee stated that the last drill was conducted on 05/10/23, the licensee was not able to produce documentation of drills conducted, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2023
Plan of Correction
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Licensee stated she will conduct the next drill on Monday, 11/06/23 and will provide proof of documentation to LPA Strother by 11/08/23. amy.strother@dss.ca.gov

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Alexis Hollon
LICENSING EVALUATOR NAME:Amy Strother
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2023


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